Pediatric Coding Alert

And make sure these modifiers don’t make a mess of your claim.

It’s a fact: kids get hurt, and when they do, they often need stitches. But in coding, things aren’t always that straightforward, and there are a number of different ways you should — and should not — code the removal of those stitches when it’s time.

Here are three tried-and-tested ways you can report suture removals, no matter whether your pediatrician or another provider performs a repair that requires the removal. To make this guide complete, we’ve also added one way that won’t work under any circumstances.

Step 1: Include Global Period Into Your Calculations

“Because removal of sutures is generally very simple to accomplish and essential to postoperative care, both Medicare and CPT^® guidelines include suture removal in the payment for the procedure itself,” notes JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis, Minnesota. This means you need to pay close attention to the global periods associated with the postoperative care for the repair procedure.

If the repair was simple, meaning that the wound your provider repaired is superficial and only requires a one-layer closure, you should choose the appropriate code from 12001-12018 (Simple repair of superficial wounds …). “Because these codes have zero-day postoperative assignments, you can bill for the removal, typically with 99211 [Office or other outpatient visit for the evaluation and management of an established patient …] if performed by a nurse or a 99212 when performed by a physician without complications or extenuating circumstances,” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts. 

If your pediatrician uses a more complex procedure to suture a patient’s laceration, things get a little trickier. An intermediate repair involving closure of a deeper (or heavily infected) wound requires using one of the codes from 12031-12057 (Intermediate repair of superficial wounds …). These codes carry a 10-day postoperative global period with them, so you cannot bill for the removal if it occurs within the 10-day period.

Step 2: Determine Context for Removal After Global

But what if your provider removes the sutures after the 10 days have expired? Can you bill separately for the service then?

Should the post-global period removal occur because of a scheduling issue, the answer is no. However, if the provider removes the sutures after the global period due to medical issues, such as the wound taking longer to heal than anticipated, then the answer is yes. You will report the same low-level established patient E/M as you would for the simple repair. Just make sure the documentation that accompanies your claim demonstrates medical necessity for the service being performed after the global period expired.

Step 3: Use This Strategy for Removal Without Repair

When one of your young patients receives sutures from an emergency room (ER) or from another provider, then comes to your pediatrician for removal, things get trickier still. That’s because there are several ways you can handle this scenario, depending on the contact your office may have with the ER or other provider.

If the original physician bills the repair, then transfer the patient’s care to your office, it is possible your pediatrician can use the repair codes for the suture removal claim. To do so, you will need to ensure that the original physician is willing to append modifier 54 (Surgical care only) to the initial procedure(s) and has confirmed that with you. This will allow you to use the same repair codes by appending modifier 55 (Postoperative management only), which could result in greater reimbursement than billing an E/M for the suture removal, especially if the original physician performed complex repair procedures on the patient.

Coding caution: “Remember that these modifiers can only be utilized on services that include a global period of either 10 or 90 days. They do not apply to services with a zero-days global period,” Walaszek notes.

Additionally, “appending modifier 55 will reduce payment to 20 percent of full procedure, with the operating surgeon getting 80 percent. Also, the surgeon and provider doing the postop care cannot be in the same practice and billing under the same practice ID number,” Witt adds.

Pro coding tip: Another code that may come into play here is S0630 (Removal of sutures; by a physician other than the physician who originally closed the wound). You’ll have to check with your payer, however, to see if the code is allowed.

Step 4: Make Sure You Don’t Make This Modifier Mistake

If you’re tempted to use 15850 (Removal of sutures under anesthesia (other than local), same surgeon) when your pediatrician initially placed the sutures or 15851 (Removal of sutures under anesthesia (other than local), other surgeon) when another physician placed them, and use modifier 52 (Reduced services) on either code to indicate that the sutures were removed without the anesthesia, don’t. You’ll be facing an almost certain denial if you do.

Why? “The intent of these two codes is to report removal of sutures under general anesthesia. Modifier 52 identifies a service that is partially reduced or eliminated at the discretion of the physician. Reporting modifier 52 to advise a payer that anesthesia was not used so the service was reduced is inappropriate because it disturbs the identification of the basic service,” Walaszek cautions.